[Treatment of proximal humeral fractures in childhood and adolescence : Consensus report of the pediatric traumatology section of the German Society for Trauma Surgery]

Abstract

Background: Proximal humeral fractures are a relatively common injury in childhood and adolescence, accounting for 0.45-2% of all fractures [2, 18]. Treatment is usually conservative but is still the subject of a scientific debate [9, 12]. In addition to the S1-LL, there are different recommendations for the diagnostics and treatment of these fractures in the literature.

Methodology: As part of the 10th scientific meeting of the SKT of the DGU, the existing recommendations and the relevant or current literature were critically discussed by a panel of experts and a consensus was formulated. An algorithm for the diagnostics, therapy and treatment was integrated into this.

Results: The measurement of axial deviation and tilt is not interobserver and intraobserver reliable [3]. The age limit for when complete correction is possible was set at an age of 10 years, as the correction potential changes around this age. For diagnostic purposes, well-centered X‑ray images in 2 planes (true AP and Y‑images without thoracic parts) is defined as the standard. At the age of less than 10 years, any malposition can be treated conservatively with Gilchrist bandaging for 2-3 weeks. Surgery can only be indicated in individual cases, e.g., in the event of severe pain or the need for rapid weight bearing. An ad latus displacement of more than half the shaft width should not be tolerated over the age of 10 years. Due to the variance in the measurement results, it is not possible to recommend surgical treatment depending on the extent of the ad axim dislocation. As a guideline, the greater the dislocation and the closer the child is to growth joint closure, the more likely surgical treatment is indicated. The development should be taken into account. The gold standard is retrograde, radial and unilateral ESIN osteosynthesis using two intramedullary nails. Osteosynthesis does not require immobilization. A follow-up X‑ray is planned for unstable fractures without osteosynthesis after 1 week, otherwise optional for documentation of consolidation after 4-6 weeks, e.g., if sports clearance is to be granted and before metal removal (12 weeks).

Conclusion: Recommendations for surgical indications based on the extent of tilt are not reproducible and seem difficult in view of the current literature [3, 9, 12]. A pragmatic approach is recommended. The prognosis of the fracture appears to be so good, taking the algorithm into account, that restitutio ad integrum can be expected in most cases.

Keywords: Conservative; Correction limits; Pediatric traumatology section; Retrograde ESIN; Treatment regimen.

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Fünfjähriger Junge nach Sturz beim Fußballspielen. a Unfallbild; b 4 Wochen nach dem Unfall mit deutlicher Kallusbildung; c 8 Wochen nach dem Unfall mit voller Konsolidierung und bereits sichtbarer Korrektur

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a Sonographische Standardschnitte am proximalen Humerus im Piktogramm (1 Anterior, 2 Lateral, 3 Posterior, 4 Medial). b Darstellung des proximalen Humerus (links die Epiphyse, nach rechts auslaufend der Humerusschaft). c Positionierung des Kindes zur schmerzarmen Untersuchung

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Algorithmus zur Behandlung von proximalen Humerusfrakturen im Kindes- und im Jugendalter

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Sechsjähriges Mädchen nach Sturz von der Schaukel; a Unfallbild; b 4 Wochen nach Unfall; c Korrektur ein Jahr nach Trauma

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Vierjähriger Junge mit Sturz vom Klettergerüst; Die Eltern waren nicht von einer konservativen Therapie zu überzeugen; Der Junge war sehr schmerzgeplagt; daher ESIN bei lediglich relativer Operationsindikation. a Unfallbild; b schrittweise Reposition mit Kirschner-Draht zur Fixation des Kopfes; c versetzte Eintrittspunkte radial, metaphysär; d Positionierung des zweiten Nagels; e finale Reposition; f postoperatives Röntgen

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a Subkapitale Humerusfraktur eines 13-jährigen Jungen mit geringer Dislokation; b extern technisch fehlerhafte retrograde ESIN-Osteosynthese mit sehr proximalem Eintrittspunkt und postoperativer Fallhand sowie sensorischem Ausfall des N. radialis; c Revisionsoperation nach 8 Tagen (gelber Asteriskus: N. radialis; gelber Pfeil: ESIN-Ende, welches den N. radialis einklemmte); d postoperative Bilder mit im weiteren konservativer Behandlung; e a.-p.-Konsolidierungsbild nach 5 Wochen; f Konsolidierungsbild nach 5 Wochen seitlich; die Fallhand war nach 2 Monaten nahezu komplett regredient, die Sensorik komplett wiederhergestellt

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Sechsjährige Zwillingsmädchen mit angelegtem Gilchrist-Verband (a) und einfachem Trageverband (b)